If you are unsure as to which plan applies to you and/or dependents, please call Member Services at 1-800-523-2846.
** All of the benefits noted on the following pages are subject to the eligibility schedule set forth in the Summary Plan Description
| Medical | ||||
|---|---|---|---|---|
| Horizon BCBS PPO PLATINUM |
Horizon BCBS PPO GOLD |
Aetna HMO PLATINUM |
Aetna HMO GOLD |
|
| PCP Visit | $20 Copay | $30 Copay | $15 Copay | $25 Copay |
| Specialist Visit | $30 Copay | $40 Copay | $25 Copay | $35 Copay |
| Emergency | $100 Copay | $100 Copay | $100 Copay | $100 Copay |
| Urgent Care | $50 Copay | $50 Copay | $50 Copay | $50 Copay |
| In-Network Deductible & Coinsurance | $250 deductible per person, $500 per family, and 10% coinsurance up to $500 per person | $500 deductible per person, $1000 per family, and 10% coinsurance up to $750 per person | $100 deductible per person, $200 per family, and 10% coinsurance up to $250 per person | $350 deductible per person, $700 per family, and 10% coinsurance up to $500 per person |
| Out-of-Network Deductible & Coinsurance | $500 deductible per person, $1000 per family, and 20% coinsurance up to $1500 per person | $1000 deductible per person, $2000 per family, and 20% coinsurance up to $2250 per person | NOT COVERED | NOT COVERED |
| Prescription | ||||
| CVS CAREMARK PLATINUM |
CVS CAREMARK GOLD |
|||
| Tier 1 (Generic) | $5 Copay | $10 Copay | ||
| Tier 2 (Preferred) | $15 Copay | $20 Copay | ||
| Tier 3 (Non Preferred) | 50% with $30 Min./$50 Max | 50% with $40 Min./$60 Max | ||
| Specialty | $100 Copay | $150 Copay | ||
| For more information regarding your prescription coverage click here:Prescription Coverage Information | ||||
| Dental PPO | ||||
| Teamsters Health & Welfare PLATINUM |
Teamsters Health & Welfare GOLD |
|||
| $2000 Annual Maximum per person | $2000 Annual Maximum per person | |||
| PPO Dental Copayments: | PPO Dental Copayments: | |||
| Oral Surgery/Extractions | $25 per tooth | $25 per tooth | ||
| Endodontic surgery (Root Canal) | $25 per tooth | $25 per tooth | ||
| Periodontal surgery | $25 per quadrant | $25 per quadrant | ||
| Crowns, bridges, etc | $30 per tooth | $30 per tooth | ||
| Partial/full dentures | $50 per unit | $50 per unit | ||
| Orthodontics (ages 10yrs-18yrs) | $100 per case (once per lifetime) | $100 per case (once per lifetime) | ||
| Find Participating Providers | ||||
| Dental Non-PPO | ||||
| All services are paid based on Non-PPO fee schedule (click for fee schedule) | ||||
| Mental Health/Substance Abuse | ||||
| Total Care Network PPO GOLD |
Total Care Network HMO PLATINUM |
|||
| IN-NETWORK (Out-patient) | $30 copay | $20 copay | ||
| IN-NETWORK (In-patient) | $500 deductible per person, $1000 per family, and 10% coinsurance up to $750 per person | $100 deductible per person, $200 per family, and 10% coinsurance up to $250 per person | ||
| OUT OF NETWORK (In-Patient & Outpatient) | $1000 deductible per person, $2000 per family, and 20% coinsurance up to $2250 per person | $500 deductible per person, $1000 per family, and 20% coinsurance up to $1500 per person | ||
| Vision | ||||
| Vision benefits are provided every 24 months provided you are eligible for benefits on the date of service. Benefits are paid based on the following allowances. | ||||
| Eye Exam | $40 | |||
| Frames | $30 | |||
| Single Lenses | $33 | |||
| BiFocal Lenses | $50 | |||
| TriFocal Lenses | $60 | |||
| Progressive Lenses | $80 | |||
| Lenticular Lenses | $115 | |||
| Contact Lenses | $80 | |||
| In order to minimize your out of pocket expenses, you can utilize an in-network provider. Find Participating Providers |
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| Death Benefits | ||||
| Death of Member | $20,000 | |||
| Death of Spouse | $1,500 | |||
| Death of Dependent Child in accordance with age as follows: | ||||
|
$300 | |||
|
$600 | |||
|
$1,200 | |||
|
$1,500 | |||
| Accidental Death and Dismemberment Benefits (Members Only) |
||||
| Loss of Life | $20,000 | |||
| Both hands or both feet | $20,000 | |||
| Sight of both eyes | $20,000 | |||
| One hand and one foot | $20,000 | |||
| One hand and sight of one eye | $20,000 | |||
| One foot and sight of one eye | $20,000 | |||
| One hand or one foot | $10,000 | |||
| Sight of one eye | $10,000 | |||
| Unlike other plan benefits which are self-insured, these Death and Dismemberment Benefits are provided through a group life policy insured by Mutual of Omaha. | ||||
| Weekly Benefits | ||||
| $250 per week | $50 per workday | |||
| If you work for a New Jersey Employer covered under the New Jersey Temporary Disabilities Law, you will receive 1/2 (half) of the disability payment indicated above. Disability benefits will commence on the first work day if the disability results from an accident or hospitalization. Benefits will commence on the sixth work day is the disability is a result of a sickness or pregnancy. Weekly disability benefits are payable for a maximum of 26 weeks. The Fund will pay you weekly disability benefits upon the initial denial of a workers compensation claim if you execute a Fund approved subrogation agreement. | ||||
** All of the benefits noted on the following pages are subject to the eligibility schedule set forth in the Summary Plan Description
We have made every attempt to provide you with as much detail as possible as it relates to your benefits however, many of these benefits have limitations as well as pre-certification requirements. You should contact the Member Services Department at 1-800-523-2846 to discuss your particular situation and not rely solely on this website.
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